Tag Archive for: Varda

Societies for Pediatric Urology logo

Children’s National at the Societies for Pediatric Urology Fall Congress

Providers from the Department of Urology at Children’s National Hospital attended the Societies for Pediatric Urology Fall Congress in October 2022 and shared a series of abstracts.

The abstracts look at unplanned healthcare use and missed visits among children with spina bifida, as well as factors associated with these outcomes. The team collected data from chart review and patient interviews to complete these projects. They considered clinical information, as well as demographic information and the childhood opportunity index, which is a composite measure that proxies social determinants of health, while accounting for how far a family lives from the emergency department.

Clinically, patients with more complex spina bifida (e.g., ventricular shunt or wheelchair use) were more likely to use the emergency department. Genitourinary and gastrointestinal problems were the most common reasons for emergency department use. Within the Spina Bifida Program at Children’s National, our providers are aggressively trying to reduce gastrointestinal complaints with a nurse practitioner dedicated to bowel management and working collaboratively with the Division of Colorectal and Pelvic Reconstruction.

A sobering finding from this research was that non-white patients with spina bifida at Children’s National were more likely to have had an emergency department visit between 2016-2020 after accounting for all other variables. This indicates a clear need for improving access, communication and quality of care for minority patients with spina bifida. We are increasingly developing our community partnerships with pediatricians and school nurses, and we are accessible by a direct phone line and email to allow for prompt support. We have also established clinics in Prince George’s County in Maryland which will bring the program closer to some minority communities.

The team also found that families of children with spina bifida scheduled for telemedicine visits were much more likely to miss a visit than a child without spina bifida or if the visit was in-person. This has led to changes in how we deploy telemedicine in this population, while still remaining nimble with the option of telemedicine or in-person visits. By screening the family’s ability and desire to use this modality, we hope to reduce missed visits overall.

View the abstracts

poster conclusions

growth of the Children's National Spina Bifida Program

A look at the Children’s National Spina Bifida Program

The Spina Bifida Program at Children’s National Hospital, led by co-directors, Christina Ho, M.D., and Briony Varda, M.D., has seen impressive growth and there are plans to continue expanding the program. Drs. Ho and Varda share insights on the multidisciplinary care being provided, along with their plans for the future of the program.

Q: How would you describe the growth of the program?

A: The growth of the Spina Bifida Program has been remarkable! The graph below really shows it all (more than a 25% increase in patient visits in the past year). We currently hold multidisciplinary programs including providers from neurosurgery (Robert Keating, M.D.), orthopaedic surgery (Matthew Oetgen, M.D.), physical medicine and rehabilitation (Mi Ran Shin, M.D.), urology (Briony Varda, M.D. and Christina Ho, M.D.), and expanded to include bowel management (Celicia Little, N.P.), gynecology (Allison Mayhew, M.D.) for our adolescent patients, as well as a dedicated nurse, Nicole Allentuck, R.N., and program associate, Christine Scott.

We are extremely proud of how the program has grown, particularly through the past two years, with the advent of our adolescent clinic and having a dedicated supportive team that ensures we have significant re-engagement of patients who had previously been lost to care. We are also working with the Prenatal Pediatrics Institute at Children’s National to enhance our prenatal care for patients diagnosed with spina bifida.

growth of the Children's National Spina Bifida Program

Q: What advancements is the spina bifida program making that benefit patients?

A: We have developed a transition clinic for our adolescent spina bifida patients to help address goals of care, independence with care and readiness for transition to adult providers. Our program coordinator, Celicia Little, N.P., also oversees our bowel management program to provide specialized bowel management care for our patients. We have been working on educational information specific to different areas within spina bifida, including how to catheterize, common medications, bowel management and anticipatory guidance. This helps to provide longevity for our patients as well.  We are evaluating ways to decrease visits to the emergency department and ensure appropriate antibiotic usage with proper diagnoses of urinary infections in patients who perform CIC.  To further our goal of providing longitudinal care within our program, we have engaged gynecology colleagues to see patients within our adolescent clinic and begin promoting independence through perpetuated discussions (e.g., are they able to schedule their own physician appointments or grocery shop for themselves?) in preparation for adult transitional care. Additionally, we readily offer telehealth visits for convenience and in hopes of easing access to care.

Q: Looking ahead, what’s next for the Spina Bifida Program? How will we continue to measure success?

A: We are excited to continue expanding our Spina Bifida Program. We currently care for more than 500 patients within the Washington, D.C., Maryland and Virginia areas. We want to continue to include patient narratives through our research initiatives to inform quality of care, including decreasing E.D. utilization and needless antibiotic use. We also want to expand our adolescent program to include sexual healthcare as they transition to adult care with our adult collaborators within MedStar and GWU. We would like to provide more comprehensive care, improve access to care, and ensure patients and families have utilization of the armamentaria of medical resources available at Children’s National.

3D Illustration Concept of Human Urinary System

Predicting surgery risk through single diuretic renogram

3D Illustration Concept of Human Urinary System

In a new study published in the Journal of Pediatric Urology, Aaron Krill, M.D., urologist at Children’s National Hospital and leading author, shows that halftime from a single initial diuretic renogram in children with antenatally detected UPJO is predictive not only of worsening future drainage, but also of future surgical repair (pyeloplasty).

The findings of a new study show promising results that will help to further subdivide the indeterminate drainage range and will help practitioners identify those children at increased risk for worsening drainage and future surgery.

So far, we know that spontaneous resolution of antenatally detected kidney obstruction, also known as ureteropelvic junction obstruction (UPJO), is relatively common. However, it can take several years and require frequent surveillance ultrasounds and diuretic renograms before patients reach a clinical outcome.

The study, which published in the Journal of Pediatric Urology, and was led by Aaron Krill, M.D., urologist at Children’s National Hospital, shows that halftime (T1/2) from a single initial diuretic renogram in children with antenatally detected UPJ obstruction is predictive not only of worsening future drainage, but also of future surgical repair (pyeloplasty).

“Among infants with UPJO, 52 to 79% can be expected to undergo spontaneous improvement,” Dr. Krill said.

Initial nonoperative management has become the standard of care for cases with indeterminate drainage patterns with preserved differential renal function (DRF). Diuretic renography has traditionally been the gold standard for diagnosis and surveillance of this condition. Identification of patients with very good drainage who can safely be discharged and those with very poor drainage who require early surgical repair has never been difficult. However, patients with indeterminate drainage have posed a unique diagnostic and therapeutic problem. Previously published ranges for indeterminate drainage were either too wide or too narrow to be clinically useful.

In the study, recent data shows a five-year surgery-free survival probability for patients with t1/2 of 5-20, 21-40 and 41-60 minutes to be: 79.7%, 46.7% and 33.3%. This suggests that patients with t1/2 of more than 21 minutes are at moderate to high risk of requiring surgery within the first five years of life while those with t1/2 20 minutes or less are at relatively low risk.

“This would allow us to concentrate our efforts appropriately on those who are at high risk of progressing to surgery and minimize the burden of testing and that of radiation exposure for children who are at low risk and likely to improve spontaneously,” Dr. Krill added.

Researchers identified patients younger than 18 months at presentation with unilateral, isolated moderate to severe hydronephrosis who underwent diuresis renography from 2000-2016. This group was sub-divided into three T1/2 intervals: 5-20, 21-40 and 41-60 minutes. Endpoints were pyeloplasty and pyeloplasty free survival. Indications for surgery were loss of DRF, worsening T1/2, family preference and/or pain.

“Being told that your newborn has an obstructed kidney and may require surgery in the future is typically a very stressful event for families,” Dr. Krill said. “Now after only a single diuretic renogram, we can provide families with accurate probability estimates of their child’s lifetime risk of surgery and risk of surgery within their first five years. This should allow us to appropriately set expectations and customize our surveillance routine for each patient.”

For decades, Children’s National has been working to refine and standardize diuretic renography. Some accomplishments over the years include establishing the safety of the test in infants, verifying its diagnostic utility, identifying new drainage parameters, and coupling it with machine learning to improve accuracy. This most recent manuscript capitalizes on a large database spanning 20 years of the team’s clinical experience to further improve the ability to predict who will need surgical repair and better counsel our patients.

Other authors include Briony K. Varda, M.D., M.P.H., Nicholas A. Freidberg, Md Sohel Rana, M.B.B.S., M.P.H., Eglal Shalaby-Rana, M.D., Bruce M. Sprague and Hans G. Pohl, M.D.

coronavirus

An analysis of articles on pediatric COVID-19 cases

coronavirus

In a recent editorial, Dr. Briony Varda commented on a systematic review and meta-analysis of articles reporting on pediatric cases of COVID-19.

In a recent editorial, Children’s National Hospital Pediatric Urologist Briony Varda, M.D., M.P.H., and Emilie K. Johnson, M.D., M.P.H., from Ann & Robert H. Lurie Children’s Hospital of Chicago, comment on a systematic review and meta-analysis of articles reporting on pediatric cases of coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.

Their take home messages were that although COVID-19 is typically milder in children than in adults, children (particularly infants) do appear to have cardiac damage from COVID-19 which may be a consideration for preoperative evaluation among surgeons. They also note the MIS-C is another emerging concern for children following an infection with COVID-19.

Read the full editorial in the Journal of Pediatric Urology.

Briony Varda

Q&A with urologist Briony Varda

Briony Varda

Briony Varda, M.D., M.P.H., is fellowship trained in pediatric genitourinary reconstructive surgery and her subspecialty interests include the care of patients with spina bifida and the neurogenic bladder, cloacal anomalies, hydronephrosis, vesicoureteral reflux and posterior urethral valves, among others.

Children’s National Hospital recognizes many urologic disorders and illnesses that are unique to children. As such, we pride ourselves in working with top urology experts, including Briony Varda, M.D., M.P.H., pediatric urologist, who recently joined the Urology Division at Children’s National.

Dr. Varda is fellowship trained in pediatric genitourinary reconstructive surgery and her subspecialty interests include the care of patients with spina bifida and the neurogenic bladder, cloacal anomalies, hydronephrosis, vesicoureteral reflux and posterior urethral valves, among others.

Here, Dr. Varda tells us more about her work and what it means for the future of pediatric urology patients at Children’s National.

Q: Why did you decide to work in this field?

I have always thoroughly enjoyed working with children. They keep you on your toes, tell it straight, make you laugh and demonstrate unique resilience. At the same time, surgery allows me to work with my hands, while being creative and helping others. Finally, I had great mentors within pediatric urology who strongly influenced me in a positive way.

In sum, the kids, the surgery and the people led me here.

Q: What is the importance of urology care?

We have three goals in pediatric urology: protect the kidneys and bladder, prevent infection and help our patients stay dry.

Although it’s usually clear when kids have urinary tract infections or trouble with urinary accidents, it’s not always visible when there is a problem with the kidney or bladder. Urologic care is therefore important because it prevents long-term damage that might otherwise go unnoticed until it is too late. This is particularly true for patients with abnormal functioning of the bladder related to a neurologic cause, such as spina bifida or a tethered spinal cord.

Q: How has the program expanded and what are some of the most valuable changes you hope to see in the next couple of years?

Our Spina Bifida Program currently includes physicians from physical medicine and rehabilitation (PMNR), orthopedics, neurosurgery and urology. Our newest additions include a full-time nurse practitioner who facilitates care coordination and has a clinical expertise in bowel management, two new urologists (myself and Christina Ho, M.D.), and Mi Ran Shin, M.D., who is our new PMNR physician.

We are also collaborating closely with the new Pediatric Colorectal & Pelvic Reconstruction Division for patients who need advanced bowel management. These additions will go a long way to helping improve the day-to-day living of our patients and help improve their long-term medical outcomes.

In the coming year, we are anticipating welcoming another full-time nurse to our program, offering more patient-facing resources including a webpage focused on urodynamics and an array of new patient education materials. We are also hoping to establish a regional transitional care network for our adolescent and young-adult patients.

Q: The Colorectal Program at Children’s National includes three urologists. How does this collaboration allow for the care of more complex cases at this hospital?

We are fortunate to be part of the Colorectal Program here at Children’s National Hospital. We provide subspecialty expertise for patients born with anorectal malformations, including cloacal anomalies and cloacal exstrophy. Although historically considered a general surgery problem, patients with anorectal malformations have a high rate of concomitant conditions affecting their genitourinary anatomy and function. By coordinating clinical care and surgery within a multidisciplinary team, we provide comprehensive care for even the most complex patients – nothing goes unnoticed and each subspecialist provides a unique perspective on management as it relates to their field.  Along with ourselves and the colorectal surgeons, we regularly collaborate with gynecology, gastroenterology, interventional radiology and anesthesia.

Q:  What is some of the research you’re working on now that you’re looking forward to the most?

We are currently designing a set of research projects aimed at investigating low-value healthcare utilization (for example, emergency room use and inappropriate testing) among patients with spina bifida. I plan to investigate institutional patterns and then expand out to the Washington, D.C., Maryland, Virginia area and the national setting. By identifying patterns in low-value healthcare utilization and their associated factors, we can ideally improve care delivery for this special healthcare needs population.

We are also working on institutional protocols to enact recently published guidelines by the Spina Bifida Association and the CDC so that we can eventually contribute our own data to national registries. This will pave the way for increasingly rigorous spina bifida research in the future.